Safety comparison of minimally invasive abdomen-only esophagectomy versus minimally invasive Ivor Lewis esophagectomy: a retrospective cohort study.

BACKGROUND: We report mortality and post-operative complications from esophageal resection in the treatment of gastroesophageal adenocarcinoma or stricture, comparing a minimally invasive abdomen-only esophagectomy (MIAE) approach with a minimally invasive Ivor Lewis esophagectomy (MIILE) approach. METHODS: A single-center retrospective cohort study of patients with esophageal adenocarcinoma or stricture treated by either MIAE or MIILE was conducted. MIAE was offered for strictures less than five centimeters or cancers that were American Joint Committee on Cancer (AJCC) Stage ≤ T2 without lymphadenopathy. Patients treated with these surgical techniques were analyzed to assess pre-operative risk, intra and post-operative variables, adverse events, and overall survival. RESULTS: This study included 17 patients undergoing MIAE and 32 patients treated with MIILE. There were a fewer median number of lymph nodes resected (p < 0.001) and shorter operative duration (p < 0.001) for MIAE compared to MIILE. MIAE patients also had significantly higher Charlson Comorbidity Index scores and ACS National Surgical Quality Improvement Program (NSQIP) surgical risk values than MIILE patients (p < 0.05). There was no difference in median estimated blood loss, length of stay, pulmonary or cardiac complications between groups. There was no significant difference in 90-day survival. CONCLUSION: A minimally invasive abdomen-only approach in a specific patient population is comparable in safety to a minimally invasive Ivor Lewis approach, with associated shorter median operative duration. MIAE patients had significantly greater pre-operative comorbidities and higher calculated peri-operative risk of complication but demonstrated similar post-operative outcomes. This suggests that MIAE may be a suitable surgical approach for treating gastroesophageal adenocarcinoma or stricture in patients deemed unsuitable for MIILE.

Peroral Endoscopic Myotomy; Novice Surgeon Learning Curve.

INTRODUCTION: Peroral endoscopic myotomy (POEM) is a novel endoscopic procedure used to treat achalasia and other spastic esophageal disorders that is an alternative to Heller myotomy. We seek to define the learning curve of POEM for a foregut surgeon with no formal endoscopic or POEM training by analyzing different intraoperative factors in a single series. METHODS AND PROCEDURES: The first 38 consecutive patients undergoing POEM by a single foregut surgeon were included in this retrospective study. Inverse curve regression models were used to analyze total operative time (TOT) and total operative time per centimeter of myotomy (TOT-CM), in addition to other intraoperative variables. Clinical outcomes were reported as pre- and post-operative Eckardt Scores. RESULTS: All patients had type II achalasia with no post-operative complications observed. Eckardt scores improved postoperatively (median (range): 1 (0-4)) compared with the preoperative scores (10 (8-12)) (P < .001). The total operative time (median 76 minutes, range 51-129) decreased significantly over the course of the series (R2 = .38, P < .001), with a learning plateau at 70 minutes and a learning rate of 12 cases. Total operative time per centimeter of myotomy (median 7.08 min/cm, range 4.25 to 15.38) decreased over time (R2 = .45, P < .001), with a learning plateau at 7 minutes/cm and a learning rate of 12 cases. CONCLUSION: The number of cases for a foregut surgeon to become proficient in a POEM procedure was found to be 12-14 cases. The learning curve for a POEM in a formally trained foregut surgeon may be comparable to an endoscopically trained interventionist.

Review of Common Clinical Conditions of the Proximal Tibiofibular Joint.

Current literature is limited with respect to the proximal tibiofibular joint (PTFJ) and clinical conditions relating to the PTFJ. Diagnosis and treatment of conditions that affect the PTFJ are not well described and are a topic of debate among many physicians. This manuscript aims to review and summarize the most recent literature that relates to traumatic dislocations, fractures, chronic instability, and osteoarthritis, with a focus on both diagnostic and treatment strategies of these conditions. We also review PTFJ anatomy, biomechanics, and the clinical presentation of some common PTFJ conditions.

Upper extremity dog bite wounds and infections.

Upper extremity dog bite wounds comprise a large percentage of all mammalian bite wounds. The purpose of the study was to assess the bacteriology of patients presenting with such injuries to the emergency room that required consultation by a hand surgeon. The study also analyzed the effect of delayed intervention on growth of invasive pathogens, on the incidence of multiple pathogens, on treatment interventions, and on length of hospital stay. Objective data and subjective descriptions of the wound were collected on 32 patients who presented to Chicago area hospitals. The authors retrospectively analyzed the data and grouped the patients into two categories based on time of intervention: early or those treated within 48 hours, and delayed to include those treated after 48 hours. Incidence of bacterial growth and Pasteurella species growth in cultures was similar to that reported in the literature. Delayed patients had a significantly higher incidence of positive bacterial growth from wound cultures (100%) compared with nondelayed patients (54%). Delayed patients also had a higher incidence of treatment intervention (delayed group 86% surgical irrigation and debridement compared with 48% for the early group). There was a trend toward increased length of hospital stay (delayed group 4.6 days compared with 2.6 days), although this was not significant. The growth of multiple pathogens between the two groups was similar and not significant (delayed group 43% compared with 54% early group).

Evidence-based guidelines for the management of Lyme disease.

This report, completed in November 2003, is intended to serve as a resource for physicians, public health officials and organizations involved in the evaluation and treatment of Lyme disease.